HEATH LANE MEDICAL CENTRE
Heath Lane, Boughton Heath, Chester, CH3 5UJ

Tel 01244 563105  E-Mail:heathlanemedicalcentre@nhs.net

Dr Chris Fryar                                      Dr Susan Wall                                               Dr Zoë Thompson

Consent to use Patient Access online
This questionnaire goes through the main issues you need to understand before you can access your medical record over the internet. It will raise questions that you may not have considered to help you to decide whether or not to access your record in this way.

To confirm your registration, 2 forms of documentation must be provided as evidence of identity. One of these must contain a photo and the other either a Utility bill or Bank/Building Society Statement dated within the last 3 months.

Please answer all the questions, deleting the answer that does not apply as appropriate. Please also use black ink as we need to scan this document to your record. Thank you

1.		Patient name		
2.		Patient date of birth		
3.		Email address (Required)		
4.		Home phone number		
5.		Mobile phone number		
6.		Are you completing this questionnaire for yourself?	YES/NO	

6b.	
If you answered NO then please state your name and relationship to the patient:	
7.		Are you registered for Patient Access allowing you to order repeat prescriptions, book appointments etc?	YES/NO	
8.		Are you happy to use a username and password to access your records?
You should not share this security information. Do you agree to not share this information?	YES/NO

YES/NO	

8b.	
If you answered NO to either question in 8, then please give your reason(s):	

If you do not want access to your Medical Records, please skip this page and continue on Page 3.
If you would like access to Medical Record Viewer, please complete the remainder of the questionnaire.

9.		After attending medical appointments, you can check if the encounter has been recorded and what was discussed. Would you find this helpful?	YES/NO	

9b.	
If you answered NO then please give your reason(s):	
10.		When accessing your medical records online, there may be instances when you may read some information that could be shocking / upsetting. You may also see hospital letters before your GP has had chance. What do you do if this happens and you cannot speak to your doctor / nurse immediately? Tick any that you feel apply;
o	Arrange an appointment to speak to a clinician at the earliest convenience
o	Look at the recommended self-care websites http://www.nhs.uk/selfcare/
o	If the practice is closed, wait and contact the practice the next working day
o	Panic and get worked up
o	Contact NHS 111 to get more information
o	Contact the Out of Hours GP Services: 01244 385300
o	Go to A&E for further help	
11.		Blood test results – If your results are normal then you can continue as before. If the results are abnormal and require action, we will contact you to make an appointment. Do you accept this arrangement?	YES/NO	
12.		Sometimes information may be recorded that is incorrect or you may believe information is missing. Would you inform the practice so that your records can be corrected?	YES/NO	
13.		Would it upset you if you read something somebody else had said about you with regards to your health?
Information like this is usually given by someone you know well and done in your best interest. It is called third party information and your record will state who provided this and what they said.	YES/NO	
14.		Do you feel that you now have a better understanding of Medical Record Access?	YES/NO	

I consent to Heath Lane Medical Centre giving me access to my medical records via Patient Access Electronic Records Viewer and agree with each of the following statements (please tick)

1.		I have read and understood this questionnaire and the information leaflet  provided by the practice		
2.		I will be responsible for the security of the information that I see or download		
3.		If I choose to share my information with anyone else, this is at my own risk		
4.		I will contact the practice as soon as possible if I suspect that my account has been accessed by someone without my agreement		
5.		If I see information in my record that is not about me, or is inaccurate I will log out immediately and contact the practice as soon as possible		

Signature

Date 

Please return this completed questionnaire with any comments via reception to the 
Practice Manager.

For practice use only
Identity verified through
(tick all that apply)	ID verified    
Photo ID 
Proof of residence 	Name of verifier	Date	
Name of person that applied changes to system		Date	
Date amendments were made		
Date scanned and read coded 		
Date confirmation email was sent to patient